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133 NOTES Pulmonary Mycetoma Due to Candida albicans: Case Report and Review Mark A. Shelly, Robert H. Poe, and Louis B. Kapner From the Department of Medicine, Highland Hospital, and the University of Rochester School of Medicine and Dentistry, Rochester, New York A pulmonary mycetoma is a round to oval-shaped mass of fungi situated within a cavity in the lung. Most mycetomas are caused by Aspergillusspecies. Other fungi have occasionally been reported to cause clinically and roentgenographically similar lesions. We report a case of pulmonary mycetoma caused by Candida albicans. Review of the literature suggests that pulmonary mycetoma due to this species is uncommon, and when it has been suspected, specific documentation has been lacking. A pulmonary mycetoma usually results from saprophytic growth of an Aspergillus species in a chronic cavity in the lung; however, other fungal species have been infrequently involved [1]. Although Candida species are common pathogens, they have rarely been associated with this type of infection. We report a case of pulmonary mycetoma due to Candida albicans. Case Report A 50-year-old man was referred for evaluation of a change that had been noted on his chest roentgenograph. He did not have any symptoms. Four years earlier, he had been admitted to a community hospital with cavitary pneumonia of the right upper lobe. He was treated for aspiration pneumonia with intravenous penicillin, and a chronic cavitary deformity remained in the right upper lobe. He had received follow-up by means of serial chest roentgenography that was performed annually. The third chest roentgenograph showed a mass lesion within the cavity (figure I). A CT scan of the chest confirmed the presence of an oblong, dependent soft-tissue mass within the cavity (figure 2). A tuberculin test with PPD and positive anergy control was negative. Bronchoscopy with brush biopsy and bronchoalveolar lavage was performed under fluoroscopic guidance. The collected material showed short nonseptate hyphal elements and budding yeast forms suggestive of Candida species. Culture yielded pure growth of Candida albicans. Identification of the species was confirmed by the New York State Department of Received 1 May 1995; revised 5 July 1995. Reprints or correspondence: Dr. Robert H. Poe, Highland Hospital, 1000 South Avenue, Rochester, New York 14620. Clinical Infectious Diseases 1996;22:133-5 © 1996 by The University of Chicago. All rights reserved. 1058-4838/96/2201-0021$02.00 Health Mycology Laboratory. No acid-fast bacilli were recovered by smear or culture. Serum antibody tests were negative for C. albicans, Aspergillus fumigatus, and Aspergillus niger. No specific treatment was rendered. Findings on repeated chest roentgenography at 8 months were unchanged. The mycetoma persists, but the patient has remained asymptomatic more than 24 months after evaluation. Review and Discussion Although Candida species have been mentioned as an occasional cause of pulmonary mycetoma, most reports are old, confirmation of the pathogen by culture has been lacking, and when culture is successful, species other than C. albicans have been recovered [2, 3]. Aspergillus species cause most pulmonary mycetomas. Other fungi can cause similar lesions; reports mention Pseudallescheria boydii, Mucoraceae, Coccidioides immitis, Histoplasma capsulatum, Blastomyces dermatitidis, Sporothrix schenckii [4], and Blastochizomyces capitatus [5] as causes of pulmonary mycetoma. In many reports little distinction is made between invasive fungal infection and the minimally invasive fungus ball. C. albicans is a common fungal pathogen that infects mucocutaneous and urinary sites more often than it infects the lung. In contrast to Aspergillus species, it generally grows as a budding yeast; mycelial forms can also be seen in clinical specimens. Candida species have caused fungus balls in other organs, including the gallbladder [6] and the urinary tract [7]. In spite of its ubiquitous distribution, convincing evidence for pulmonary mycetoma due to this pathogen is rare. A MEDLINE search of the English-language literature did not reveal any recent reports of Candida species as a cause of pulmonary mycetoma. Schwarz et al. [8] reported four cases of pulmonary mycetoma and reviewed the literature of socalled aspergillomas in 1961. Among 58 cases, they identified 134 Shelly, Poe, and Kapner two in which a fungus ball was possibly due to Candida species. In one case, originally reported by Graves and Millman [9], a "monilial-like" organism was recovered from the sputum of a man with a large lung cavity. A needle biopsy was performed, and the lesion was subsequently resected. The organism was described as resembling Aspergillus morphologically, but cultures of the tissue were sterile. In the other case, which was one of four involving fungus balls that were originally reported by Levin [10], the organism was morphologically "possibly Candida or a Phycomycetes species." Attempts at culture were unsuccessful. In another two of the four cases, organisms were found at resection that were "indistinguishable" from those found in the first case. All cultures were negative, and the fungi were termed "unidentified." Lodin [11] reported a 1956 case of pulmonary mycetoma that contained a calcified mass from which Candida species were recovered. There is no reference to culture, and it is presumed that identification was morphological. Kennedy [12] reported a case of bronchopulmonary moniliasis in a patient with a cavity in the superior segment of the left lower lobe. C. albicans was recovered from the sputum, but no fungus ball was found on resection, although the cavity contained spore forms with mycelia that were consistent with C. albicans. Distinct "small black particles" seen in the sputum that are not typical of Candida species suggest that another pathogen caused this case of pulmonary mycetoma. em 1996;22 (January) Figure 2. Confirmatory CT scan of the chest of the patient described in figure I showing a dependent mass lesion lying within a cavity, consistent with pulmonary mycetoma. More recently, Watanakunakom [13] reported a case of acute pulmonary mycetoma due to C. albicans in a patient with a relapse of acute myelogenous leukemia. However, in this case the patient was granulocytopenic and had no preexisting cavity; the lesion, including the cavity, responded to systemic antifungal therapy. In the case described herein, C. albicans was identified morphologically on pathological examination of specimens, and this identification was confirmed by culture. No other organisms were identified. Mycetomas are rarely visualized endoscopically [14], but there was no question that the specimens obtained by bronchoscopy were representative of pulmonary mycetoma since the procedure was performed with fluoroscopic guidance. Virtually all patients with aspergillus pulmonary mycetoma have serum precipitins to Aspergillus species [15]. Our patient's negative test for serum precipitins to A. fumigatus and A. niger made concomitant aspergillus infection unlikely. Our patient also was negative for agglutinins to Candida species. Precipitins to Candida species are formed only in response to systemic infections, and hence this finding is expected [16]. We believe that this is the first case of C. albicans pulmonary mycetoma in which the diagnosis was established beyond a reasonable doubt both by morphology and by culture. References Figure 1. Posteroanterior roentgenograph of the chest showing a large cavity containing an intracavitary mass in the right upper lobe of a patient with pulmonary mycetoma due to Candida albicans. 1. Fraser RG, Pare JAP, Pare PD, et aI. Infectious diseases of the lungs. In: Fraser RG, Pare JAP, Pare PD, et aI., eds. Diagnosis of diseases of the chest. 3rd ed. Philadelphia: WB Saunders, 1989:991. em 1996; 22 (January) Pulmonary Mycetoma 2. Oldfield FSJ, Kapica L, Pirozynski Wl Pulmonary infection due to Torulopsis glabrata. Can Med Assoc J 1968;98:165-8. 3. Hainer JW, Ostrow JH, Mackenzie DWR. Pulmonary monosporosis: report ofa case with precipitating antibody. Chest 1974;66:601-3. 4. Hemoptysis and pulmonary cavitation in a 37-year-old man [clinical conference]. Am J Med 1991;90:628-32. 5. Martino P, Girmenia C, Venditti M, et al. Spontaneous pneumothorax complicating pulmonary mycetoma in patients with acute leukemia. Rev Infect Dis 1990; 12:611-7. 6. Magnussen CR, Olson JP, Ona FV, Graziani Al, Candida fungus balls in the common bile duct. Arch Intern Med 1979; 139:821-2. 7. Turner RW, Grigsby TH, Enright JR, et al. Anuria secondary to mechanical obstruction caused by a Candida fungus ball. J UroI1973; 109:938-40. 8. Schwarz J, Baum GL, Straub M. Cavitary histoplasmosis complicated by fungus ball. Am J Med 1961; 31:692-700. 135 9. Graves CL, Millman M. Lobectomy for fungus abscess of the lung: effect of penicillin. J Thorac Surg 1951;22:202-7. 10. Levin EJ. Pulmonary intracavitary fungus ball. Radiology 1956;66:9-16. 11. Lodin H. Roentgen diagnosis of pulmonary mycetoma. Acta Radiol 1957;47:23-8. 12. Kennedy JH. Bronchopulmonary moniliasis. J Thorac Surg 1959; 37: 231-5. 13. Watanakunakorn C. Acute pulmonary mycetoma due to Candida albicans with complete resolution [letter]. J Infect Dis 1983;148:1131. 14. Smith RL, Morelli MJ, Aranda CPo Bronchopulmonary aspergillorna diagnosed by fiberoptic bronchoscopy. Chest 1987;92: 948-9. 15. Longbottom JL, Pepys J, Clive FT. Diagnostic precipitin test in Aspergillus pulmonary mycetoma. Lancet 1964; 1:588-9. 16. Stallybrass FC. Candida precipitins. J Pathol BacterioI1964;87:89-97.